Claim Adams, Sandra G.CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: Sandra G. Adams
2. Address: 1373 Iowa St. Apt. 1 Dubuque,IA 52001-4824
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3. Telephone Number: (563) 556 3770
4. Date of Incident: May 15, 2004
5. Time of Incident: Approx. 8:30 A.M.
6. Location of Incident (Be specific):
In front of 1129 Iowa St.
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full details upon which you base your claim. If a City employee was involved, give the employee's name.)
I tripped on projecting sidewalk in front of 1129 Iowa St. on sidewalk that projects 1" to 1 1/2 " above ground which caused the fall that broke 2 ribs/left side.
8. What were weather conditions like? Sunny/Cool
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.) No.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Yes, Myself (Claimant) I suffered bruised knees, two broken ribs, left side of chest
12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.)
No
13. What other damages do you claim, if any?
Incapacitation of activities do to broken ribs, for possibly a month to 6 weeks, not able to do normal activities.
14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount paid.)
No
15. What amount do you claim from the City of Dubuque?
$250.00 for medical expenses (xRays, Doctors Exam) and $1000 dompensation for inconvenience and restrictoins due to injuries.
16. Why do you claim the City of Dubuque is responsible?
Because Cityof Dubuque should have seen to the repair/safety of sidewalk and/or should have notified owner of building about necessity of repairing sidewalk.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa this 25 day of May, 2004. .
/s/ Sandra G. Adams
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUErlOWA ~ø
This written report constitutes your claim against the City of Dubuque, Iowa. You should
complete this form in full and attach any additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. ,.
It will then be referred by the City Council to the appropriate department for investigation. .
Once that investigation is completed, a report and recommendation will be submitted to the
City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE
OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO
YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: 8AJJDQ-A fi, HOffH,::s
2. Address: 17> J~ }öwfj ST. ÃP""r, ¡"Üi-IBUrJU,r;,!A,Sf)oo/<4ß!)+
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3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City employee was involved, give the
employee's name.)
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8. What were weather conditions like? .5 U /J IV Y / c'n () /
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9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of damages.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
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13. What other damages do you claim, if any? I/J c.,A- P h(!. ( -17tj¡ (\ ¡..j (j F j'tG-Tl'f't::r[£"S
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14. Have you been compensated for any part or all of your claim by any insurance
company? (If so, give name and address of insurance company and amount paid.)
NO
15. What amount do you claim from the City of Dubuque? it~SO°Q, F-o fíì- /'fë.& ICYJ L.
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16. Why do you claim the City of Dubuque is responsible? /3ß"ŒÆ-uS&, dt,7Y d:"C"
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
MCJ
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this
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(Rev. 1/00 & 7/01)